SETTING THE AGENDA: DATA DRIVEN ADVOCACY TO ADDRESS HOME CARE AIDE POLICY

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www.hcacouncil.org  124 Watertown Street, Suite 2E  Watertown, MA 02472  Phone (617) 744-6561  Fax (781) 209-5977

SETTING THE AGENDA:

DATA DRIVEN ADVOCACY TO ADDRESS HOME CARE AIDE POLICY

Tufts Health Plan Foundation

Authors

Hayley Gleason, MSW, MS

Contributors

Natalie Shellito Lisa Gurgone, MA Caitlin Coyle, PhD

February 2018 Grantee

Home Care Aide Foundation

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Acknowledgments

The Home Care Aide Foundation would like to thank our funder, the Tufts Health Plan Foundation for their support of this our work, generally, and of this project. Without their generous commitment to this effort, the execution of a high-quality assessment of the home care industry in Massachusetts would not have been possible.

We would also like to thank the home care agencies and home care aides that took the time to participate in this project by completing surveys, participating in focus groups, interviews, or by providing staff time to support any of these efforts. Finally, we want to acknowledge the time and energy of our Advisory Committee members. These home care agency and community organization partners supported the development of the survey tools as well as provided guidance and feedback throughout the grant period.

Members of the Advisory Committee include:

Edward McGonagle, Greater Boston Home Health Care Services Michelle McGonagle, Greater Boston Home Health Care Services Nancy Munson, Bristol Elder Services, Inc.

Robert Schaeffer, Multicultural Home Care Kevin Hunter, Anodyne Services

Angela Rocheleau, Associated Home Care

Leanne Winchester, Executive Office of Elder Affairs Kelly Aiken, Jobs for the Future

Mary Kay Brown, Massachusetts Association of Councils on Aging Christine Bishop, Brandeis University

Caitlin Coyle, University of Massachusetts Boston

The Home Care Aide Council and Foundation

The Home Care Aide Council (Council) is a non-profit trade association with over 150 members throughout Massachusetts committed to enhancing quality of care throughout the home care industry by focusing on the advancement of the home care aide workforce.

Home care aides are the heart of the Commonwealth's home care system, providing personalized and supportive services that enable our elders and disabled children and adults to remain at home. The Council works with state agencies, the Legislature, the media, and the general public, providing timely information and education on home care services and advocating for priority home care issues and initiatives.

Throughout our history, the Council has brought together providers from certified home health, homemaker, and private pay agencies to ensure that quality home care aide services are delivered throughout Massachusetts. The Council has been the leader in setting standards for home care aides and is proud to serve as the question and referral source for standards of practice.

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Executive Summary

Despite a growing demand for elder care, particularly care provided in the home, the supply of home care workers is falling short. The instability of the home care workforce, caused by high turnover, increasing vacancy rates, and shortages of quality home care aides, is leading to a crisis in the long-term services and supports system (Seavey & Marquand, 2011). With over 1 million new home care aide positions needed by 2026 to meet the needs of the country’s aging boomers, the supply of workers will not meet the demand (PHI, 2017). The older U.S. population is anticipated to grow by 128% between 2010 and 2050, yet labor force participation by women aged 20-64, the traditional source for direct care workers, will only increase by 1.2 million from 2014-2024. This is in stark contrast to the growth from 2004-2014, which was nearly 7.3 million. Without the supply of new workers available to bring into the industry and the serious deficit in home care agency’s ability to retain those who are currently employed, there will soon be a serious care gap facing our country’s older adults and people with disabilities.

No state-level data currently exists to describe this workforce, let alone identify barriers to entering the workforce and create mechanisms for retention. Without information, we are unable to answer the question “why” when discussing the enormous problems of recruitment and retention. The necessary changes needed to solve this impending crisis rely on setting priorities for action, driven by data, and innovative policy initiatives.

To address this need, The Home Care Aide Foundation (hereto referred to as the Foundation) was awarded a Policy and Advocacy Community Investment grant from the Tufts Health Plan Foundation in January 2016 to generate an evidence-based policy agenda to guide the Massachusetts State Home Care Program, as well as the home care industry as a whole. This agenda specifically identifies and prioritizes areas for policy change and legislative action and can be found on the Home Care Aide Council’s website.

The results from the assessment efforts to gather timely and relevant data on the industry used to develop the policy agenda are detailed in this report.

Method

Two surveys were developed, pilot-tested and administered by the Foundation in 2016. One survey was directed at home care agencies in order to describe and characterize the industry as a whole. Thanks to the support provided from the Executive Office of Elder Affairs and the University of Massachusetts Medical School, the Home Care Agency survey was embedded in the online system that administered the 2016 Homemaker Notice of Intent to Contract (NOI) Application. This application is the means by which home care agencies apply to participate in the State Home Care Program. The 2016 application period was a unique opportunity to collect survey data from all home care agencies. Though the NOI was required, the Agency Survey was voluntary. In the end, 135 agencies had contracts to work within the State Home Care Program and 58 of these completed the survey, resulting in a 43% response rate.

The second survey was developed to survey home care aides in Massachusetts about their work experience and perception of the industry. This survey was available in four languages: English, Spanish, Haitian Creole, and Russian. A stratified random sample of ten home care agencies that responded to the

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4 Home Care Agency Survey (N=58) was used to select agencies for participation in the Home Care Aide Survey. Agencies were stratified by geography to account for anticipated differences in home care aide experiences depending on their location. Initially, ten agencies were selected, but the Western region was underrepresented, so an additional agency was chosen. A total of 656 home care aides responded to the survey during the late summer, early fall 2017, resulting in a 22% home care aide response rate.

Finally, three stakeholder focus groups were conducted with provider organizations, academic and government agency representatives, and aging network stakeholders (N=24) and four focus groups with home care workers (N=30) were conducted. The focus groups assisted in contextualizing the results from the surveys and in identifying barriers that could be alleviated through changes in policy, as well as providing specific recommendations for changes to policy and practice.

Findings

Description of Respondents

• The home care agency responders were made up of primarily non-Medicare Certified agencies (74%) and had an average of 153 home care aides on staff who provided care to 478 clients.

• The home care aide workforce is a part-time or per diem workforce, with 65% of the agency’s home care aide workforce being part-time and home care aides working on average 26 hours per week

• Over 40% of the home care aide workforce has been with their current agency for less than one year, though the aides overall are quite experienced, with nearly half having worked as a home care aide for five years or more

• Home care aides rely heavily on MassHealth for their health insurance with only 5% stating that they access insurance through their employer. Agencies report a slightly higher take-up of their health insurance, on average 11% of their home care aide workforce access their insurance

• 47% of home care aides have more than one job, either working as a home care aide at multiple agencies, working as a CNA or PCA in another health care setting, or working in another industry outside of health care

• Home care aides are primarily female (96%), with an average age of 48, with limited education (50% have a high school diploma or less), and 48% were born outside the United States

o Nearly 80% have household incomes below $40,000 per year

o 48% have an outside caregiving responsibility, caring for a child, other family member, or friend

▪ On average, among those with children under 18, one day of work is missed per month due to a child’s illness, medical appointment or lack of childcare

Challenges to the Home Care Industry

• Recruitment of qualified aides is the number one challenge related to the home care aide workforce reported by home care agencies in the survey.

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5 o One challenge to recruitment is cost related to training new workers due to the lack of reimbursement for such training. Among responding agencies, 51% offer homemaker, 37% offer personal care homemaker, and 35% offer home health aide.

• Retaining home care aides already employed is also a major concern. The average quarterly turnover rate is 16% and agencies are only netting three new employees every three months when accounting for those that left.

o Though home care aides report being relatively satisfied with the job, a large proportion intend to leave within the year.

• The average rate of pay reported by home care aides was $12.77. Home care aides report high dissatisfaction with the pay and note it as one of the largest challenges with staying in this workforce.

• Home care aides also report that the lack of benefits available to them through their job make it challenging to stay. Only 63% of agencies offer vacation time to their full-time aides, and 53% to their part-time workers. Retirement and disability are much less frequently offered, at 32% and 21% for retirement to full-time and part-time workers respectively, and 16% and 14% for disability.

• The schedules and hours of home care aides appears to be a major problem for agencies and the aides that fill the positions. Agencies report challenges filling both weekend and weekday cases.

Aides state that the one-hour shifts, and variable schedules make it hard to maintain a consistent schedule and work only one job. The short shifts also require additional travel, which on average, home care aides are already spending over 40 minutes of their day doing

o 42% of home care aide report wanting to work more hours than they currently are o Of the 54% who are on at least one public benefit (including MassHealth), 31% state they

have reduced their hours to become or remain eligible for the benefits

• Home care aides report not feeling appreciated and not having opportunities for training and advancement in their job. They also often do not have the information they need about their clients to be successful in their work. Better integrating them into the care team and providing them with up-to-date information would help to show the value of their work.

Recommendations

Increase Recruitment Efforts

To address the need for increasing recruitment of home care aides, the following changes to policy or practice are recommended:

• Recommendation #1: Identify mechanisms to make initial training low-cost or free to individuals interested in pursuing a career in home care

• Recommendation #2: Improve the supports provided to trainees and new workers to ease the transition into work

• Recommendation #3: Develop innovative partnerships with community-based organizations to recruit and support younger and non-traditional workers into the field

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6 Improve Retention

To address the high rate of turnover among home care aides, the following changes to policy or practice are recommended:

• Recommendation #1: Work with the Massachusetts’ Legislature to increase wages and improve the benefits offered to home care aides employed by home care agencies

• Recommendation #2: Invest in programs and pilot innovative partnerships and models that support home care aides to manage the personal and work life challenges that threaten their ability to remain on the job

Maximize Hours Currently Worked

To address the need to better utilize currently employed home care aides, the following changes to policy or practice are recommended:

• Recommendation #1: Address the rise in short shifts by increasing rates to support the differentials paid to aides for these undesirable shifts and provide consistent, higher reimbursement for travel

• Recommendation #2: Work across state agencies to review various program requirements and engage in a system wide approach to address the benefit cliff issues that force home care aides to limit their hours

Stabilize Schedules

To address the need to stabilize the schedules of home care aides, the following changes to policy or practice are recommended:

• Recommendation #1: Develop innovative ways to better cluster clients to improve scheduling and decrease travel

• Recommendation #2: Adopt and adequately reimburse agencies for full-time home care aide positions

Up-Skill and Integrate

To address the need to advance the professional skills of the current workforce, arm them with adequate information, and embed them in the wider healthcare team, the following changes to policy or practice are recommended:

• Recommendation #1: Invest in the creation of new up-skilling opportunities for home care aides and ensure that state-level workforce funding is designed to support the ongoing training needs of the home care aide workforce

• Recommendation #2: Increase the information provided to home care aides through the use of technology

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• Recommendation #3: Improve the training provided to home care aide supervisors to ensure aides are properly supported and communication is enhanced

• Recommendation #4: Partner with managed care entities to begin to build new models for care delivery that include the home care aide as an integral team member

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Section 1. Background

The instability of the home care workforce, caused by high turnover (between 40%-60%), increasing vacancy rates, and shortages of quality home care aides, is leading to a crisis in the long-term services and supports system (Seavey & Marquand, 2011). With an anticipated 1.1 million new direct care positions needed by 2018 to meet the needs of the country’s aging boomers, the supply of workers will not meet the demand. By 2050, the older U.S. population is anticipated to reach 88 million, nearly doubling from its size today of 47.8 million (He, Goodkind, & Kowal, 2016). However, labor force participation of women aged 20-64, the traditional source for direct care workers, will increase by only 1.2 million throughout the next decade (PHI, 2017). Without the supply of new workers available to bring into the industry and the serious deficit in home care agency’s ability to retain those who are currently employed, there will soon be a serious care gap facing our country’s older adults and people with disabilities.

Massachusetts struggles with similar workforce challenges like the rest of the nation, such as an increasing demand for home care aides to care for individuals in community-based settings, but a shortage of available workers. Throughout the Commonwealth, the demand for Home Health Aides is expected to increase by 38% from 2014 to 2024, or an annual percent change of 3.24%, making it the fastest growing occupation in the state. Home care aides (HCAs) are not far behind, with the demand anticipated to grow by 25% (2014-2024). In contrast, jobs overall during this time period are expected to increase by only 3 percent (Bureau of Labor Statistics, 2017).

The purpose of the project, “Setting the Agenda: Data driven advocacy to address home care aide policy”

was to execute a Massachusetts home care workforce and industry study to understand the current status of the State Home Care Program workforce and industry, as well as identify priority areas for policy change or legislative action.

The mixed method data collection included 7 focus groups and 2 surveys. The agency survey tool was developed based on the State Profile Tool-Direct Service Worker Survey (DSWS), conducted in April 2012 to gather data on the direct-service workforce in the state. Additional questions tailored to the home care workforce (as opposed to the direct-service workforce more broadly) were added to evaluate the challenges and successes home care agencies experience. Building on this industry-survey, a home care aide-level survey was developed and distributed among this workforce. Three stakeholder focus groups with provider organizations, academic and government agency representatives, and aging network stakeholders and four focus groups with home care workers were conducted. The focus groups assisted in contextualizing the results from the surveys and in identifying barriers that could be alleviated through changes in policy, as well as providing recommendations for changes to policy and practice.

Two reports were written at the conclusion of the project; the data report included here and a report outlining policy recommendations which align the findings from the multiple data sources. The Recommendations Report can be found on the Home Care Aide Council’s website: www.hcacouncil.org.

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Section 2. Home Care Agency Survey

Survey Development

The purpose of the Home Care Agency Survey was to collect agency-level information about the organization, such as the service they offer and the state or federally funded programs they participate in, and the home care aides they employ (see Addendum A for a full copy of the survey). The goal of the survey data was to help inform the home care network, policymakers and key healthcare leaders about the current status of the home care industry as it relates to the home care workforce. Initially, questions were drawn from the State Profile Tool- Direct Service Worker (DSW) Survey conducted in April 2012 to gather data on the DSWs in the state. Because this survey tool was developed for a broader population of workers, the questions were then tailored for the home care industry. A Project Advisory Committee was established to review the survey tool and make suggestions. In addition to review by the Project Advisory Committee, the Home Care Aide Council’s Standards Committee and the Council’s Board also reviewed the survey questions and provided feedback. Outside of the Council’s member agencies and their staff, three representatives from Aging Services Access Points were consulted, along with a representative from the Executive Office of Elder Affairs (EOEA), University of Massachusetts Boston Gerontology Department, and University of Massachusetts Medical School. The survey was pilot tested with five home care agencies of varying sizes and geographic locations. The final version of the survey included 29 questions and was anticipated to take the home care agency approximately 30 minutes to complete.

Data Collection

Because of the complexity of the home care industry, the Foundation was intentionally explicit about the target agency population for this assessment. Though there are numerous other home care agencies, such as those who work with private pay clients only or provide services through Medicare as a Certified Home Health Agency, the goal of this survey was to collect current information from those home care agencies that currently have contracts with ASAPs to work within the State Home Care Program. The timing of our survey happened to correspond with the launching of a new system through EOEA, resulting in all home care agencies (even those with current contracts) to submit a full NOI application. In most years, agencies that already had contracts were only required to go into the system and update their information. But, with the launching of the new site, all agencies had to access the program within a particular time period, offering us a unique opportunity to draw the attention of these organizations. Thanks to the support provided from EOEA and the University of Massachusetts Medical School, the Home Care Agency survey was thus embedded in the online system which housed the 2016 Homemaker Intent to Contract Application. Upon entering the site, agencies were prompted to complete the survey. The survey was not required of agencies and they could submit the NOI application without completing the survey. The survey was available for agencies to complete on this system from August 1, 2016 through February 1, 2017. This time period was not set in advance but the survey was closed when very few new surveys were being submitted. During this time, the Home Care Aide Foundation was available via phone or email for questions or to assist agencies in completing the survey.

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Results

In total, 106 home care agencies completed the Home Care Agency Survey. Of these, 58 had current contracts to work within the State Home Care Program. The other 48 did not have a current contract but were applying to be eligible to secure a contract with an ASAP. At the time of the data collection, 135 agencies had current contracts to work within the State Home Care Program. The list of agencies with current contracts was obtained from EOEA and was then cleaned for duplicates (due to mergers or name changes) or closers by the research team. This resulted in a 43% response rate for home care agency responders with current ASAP contracts. Also obtained from EOEA was the volume of State Home Care Program business (percent) for all home care agencies with at least one contract with an ASAP. Figure 1 shows the distribution of the survey responders in terms of volume of ASAP business. The responder agencies accounted for 54.6% of all ASAP volume across the state. Additionally, 12 of the largest 20 agencies responded to the survey. Though our response rate was under 50%, we are encouraged that the volume of business for our responders was higher, showing that those who participated make up a large share of the State Home Care business, giving a relatively accurate picture of the home care industry landscape.

Figure 1. Agency Responders by Volume

Smallest to Largest Agencies by Volume

Description of Home Care Agency Respondents

As shown in Figure 2, the agencies varied considerably in size, determined by the number of clients they provide services to and the number of home care aides they employ. However, the majority of the agencies fall in the ‘small’ agency category, with fewer than 500 clients and less than 100 home care aides.

The average client count for the agencies was 478 clients, with 153 home care aides on staff. At the time of the survey, the sample of agencies employed was 9,302 home care aides. When looking at the change in clients over time, the majority of agencies reported relative stability in their numbers, with an average of three additional clients over a one month period.

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11 Figure 2. Size of Agency by Client and Aide Counts

Although all of the agencies participate in the State Home Care Program, the majority also participate in other state or federal programs in addition to offering private pay services (Figure 3). Across all of the responder agencies, an overwhelming 74% have a private pay side of their business, offering home care services to consumers directly for a fee. In addition to private pay, 57% also have contracts to provide services to older adults with Senior Care Options (SCO). Under this program, the elder must receive all of their health-related services from within their Senior Care Organization’s network. SCO primarily serves older adults who are dually eligible for Medicare and Medicaid and provides them with comprehensive services including long-term services and supports (LTSS). The home care agency becomes a provider within one of the five Senior Care Organization’s networks to provide these LTSS services to those elders that require them. Further, 45% of the agencies contract with the state through the Massachusetts Rehab Commission’s Community Living Division to provide disabled adults with homemaking services. Many certified home health agencies (26%) that have contracts to receive funding and provide services to individuals with Medicare also participate in the State Home Care Program. Additionally, 26% of the agencies participate in the OneCare program, designed for individuals under age 65 who are dually eligible for Medicare and Medicaid. Like with the SCO program, agencies contract with the One Care provider to offer LTSS services to individuals that need them. Over one fifth of the agencies (22%) participate in the Acquired Brain Injury and Traumatic Brain Injury waivers, offering homemaking and personal care to individuals who qualify through the Massachusetts Rehab Commission Community Based Services department and MassHealth. A demonstration program, Money Follows the Person (MFP), has the goal of assisting older adults and people with disabilities on MassHealth to move from facility settings back into the community. Within this sample, 14% of agencies contract to provide services to those who participate in the program and return to the community. Since the time of the survey, the MFP demonstration stopped enrolling new enrollees (August 31, 2016) though services can still be delivered

0 500 1000 1500 2000 2500 3000 3500 4000

0 100 200 300 400 500 600 700 800 900

Client Count

Aide Count

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12 to those in the program until the final end date of the demonstration on December 31, 2017. The program with the lowest participation among the agency responders are those services offered by the Massachusetts Commission (MCB) for the Blind. 10% of the agencies have contracts to provide services to individuals that qualify through the MCB.

Figure 3. Current Contracts, Percent of Agencies

*Respondents were instructed to ‘select all that apply’ and therefore responses do not sum to 100%.

As noted above, 26% of the home care agencies that participate in the State Home Care program are Certified through the Department of Medicare and Medicaid to provide home health services to individuals in Massachusetts that have Medicare (Figure 4). Recently, many of these certified agencies primarily employ professional staff, such as nurses, physical therapists and occupational therapists, and have moved away from employing home health aides on staff. A large number now contract with non- certified home care agencies to provide the services required of home health aides. From this sample, 26% of the agencies fall into this category, meaning that they are not certified to provide Medicare funded services, but have contracts with certified agencies to provide these services. The remaining 47% of the agencies are not certified nor do they contract with certified agencies to provide home health aide services.

10% 14%

22% 26% 26%

45%

57%

74%

0%

10%

20%

30%

40%

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60%

70%

80%

Mass Comm

Blind

MFTP ABITBI Waiver

OneCare Medicare HH

MRC SCO Private Percent of Agencies that Participate Pay

Program

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13 Figure 4. Types of Home Care Agencies

In addition to finding out information about the types of agencies that participate in the State Home Care program, it was also important to understand the types of services that the agencies offer to clients (Table 1). 100% of the agencies provide homemaker and personal care services and 86% offer companion services or home health. Nearly 70% of the agencies have Alzheimer’s Supportive Home Care Aides (SHCAs) on staff and are able to offer this service, though only 53% of agencies have the equivalent Mental Health SHCA service available. Finally, 41% of the agencies offer chore services to clients in the community (See Addendum B for a full description of each of the services).

Table 1. Services Offered by Agencies

Service Percent (%)

Homemaker 100%

Personal Care 100%

Companion 86%

Home Health 86%

Alzheimer’s Supportive Home Care Aide 69%

Mental Health Supportive Home Care Aide 53%

Chore 41%

To better understand the training being offered to home care aides by agencies, responding agencies were asked to report on which trainings they currently offer or make available to new or incumbent home care aide employees. Nearly 60% of the agencies offer the Alzheimer’s Supportive Home Care Aide (SHCA) training to their home care aides (Table 2). Following this SHCA training, the most commonly offered agency-based training is the 40-hour Homemaker training (50.9%). Few agencies make available the Mental Health Supportive Home Care Aide training (38.6%), the 60-hour Personal Care Homemaker

26%

24%

47%

Medicare Certified Agency

Non-Certified that Contracts with a Certified Agency Non-Certified Agency Only

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14 training (36.8%), or the 75-hour Home Health Aide training (35.1%). 26.3% of the agencies reported that they offered ‘Other’ training, which was most often written in as monthly in-services or on-going continuing education.

Table 2. Trainings Offered by Agencies to their Home Care Aide Employees

Training % Offering Training

Alzheimer’s Supportive Home Care Aide 57.9%

Homemaker 50.9%

Mental Health Supportive Home Care Aide 38.6%

Personal Care Homemaker 36.8%

Home Health Aide 35.1%

Other 26.3%

Chore 41%

Home Care Aide Workforce

Agencies were asked to report on characteristics of their home care aide workforce in order to better understand the work experience of these aides, as well as how home care agencies are utilizing them at their agency. The majority of the agency’s home care aide workforce works part-time, 65%, with 35%

working full-time (Figure 5). The definition for full-time varies from agency to agency, with the majority, 60%, considering 30-35 hours full-time and the remainder of agencies considering greater than 35 hours full-time.

Figure 5. Percent of Full-Time versus Part-Time Home Care Aides, Mean

35%

65%

% Full Time Aides

% Part Time Aides

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15 On average, 58.2% of the home care aides employed at the agency had been there for more than one year, but a large percent were new hires (Figure 6). 22.7% had been employed at their agency from six to twelve months and 19.1% had been employed for less than six months. The relatively high rate of new employs could be an indication that the agency has increased recruitment efforts to grow their workforce and increase the total number of aides they employ overall. Unfortunately, the data indicates that it is more likely that the agencies actively recruit and bring in new aides to primarily replace those that have left due to voluntary and involuntary turnover.

Figure 6. Length of Home Care Aide Employment, Mean

The Massachusetts home care aide workforce is older than the workforce nationwide. Nationally, 5.9% of the labor force is made up of people over the age of 65 (BLS, 2017), whereas 8.5% of the home care aide workforce falls in this age category (Figure 7). In total, over a third, or 33.6% of the home care aide workforce, is over the age of 50. Nationwide, the home care aide workforce typically draws older workers, and the findings from this survey support this trend.

19.1% 22.7%

58.2%

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70%

% Employed Less than 6 Months

% Employed 6 to 12 Months

% Employed More than 12 Monts

Percent of Home Care Aide Workforce

Length of Employment

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16 Figure 7. Home Care Aide Age Categories, Mean

Agencies were asked to report the average starting wages and the highest wages of their employees in each of the five types of home care aide positions: companion, homemaker, personal care homemaker, home health aide, and supportive home care aide. Unsurprisingly, the wages of each of the jobs rose with the advanced positions in both starting and highest wages (Figure 8). The exception to this was the highest wages for supportive home care aides, which, on average, was lower than home health aides highest wage by $0.15. The average wage indicated in Figure 9 is an average of the starting and highest wages. This data is similar to the Bureau of Labor Statistics data for June 2016 reporting that home care aides in Massachusetts make on average $13.59, compared to the average reported by our agencies of $12.94 for homemakers and $13.20 for personal care homemakers. The BLS reported an average rate of pay of

$14.04 for home health aides, also close to the rate reported by the home care agency responders of

$13.87 for home health aides and $14.12 for supportive home care aides (who would be classified as home health aides in the BLS data).

20.0%

46.4%

25.1%

8.5%

0%

5%

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35%

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50%

% Age 19 to 30 % Age 31 to 50 % Age 51 to 64 % Over 65

Percent

Age of the Workforce

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17 Figure 8. Home Care Aide Starting and Highest Wages, Means

Figure 9. Average Hourly Wages, by Type of Worker

$12.14

$12.94

$13.20

$13.87

$14.12

$11.00

$11.50

$12.00

$12.50

$13.00

$13.50

$14.00

$14.50

Companion Homemaker Personal Care Homemaker

Home Health Aide

Supportive Home Care

Aide

Wage

Type of Worker

$11.33 $12.95 $11.88 $12.18 $12.52 $13.18

$14.00 $14.21

$15.21 $15.06

$0.00

$2.00

$4.00

$6.00

$8.00

$10.00

$12.00

$14.00

$16.00

Companion Homemaker Personal Care Homemaker

Home Health Aides

Supportive Home Care

Aides

Wage

Type of Worker

Starting Wage Highest Wage

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18 Massachusetts requires that all employers offer full-time employees health insurance, but other benefits are not required. On average, home care agencies do offer other benefits including vacation time, retirement, disability insurance and others (Figure 10). The most often offered benefit to both full and part-time home care aides is vacation time, with 63.2% offering it to their full-time aides and 52.6%

offering it to their part-time aides. Second to vacation is retirement benefits or 401k plans, with 31.6% of agencies offering the benefit to their full-time aides and 21.1% making it available to part-time aides.

Though home care agencies are required to offer health insurance to their employees, the uptake among home care aides is extremely low. On average, only 10.9% of the home care aide workforce receive health insurance benefits through their agency employers. Though, 70% of the agencies only have 6% or less of their home care aide workforce enrolled in their company offered health insurance plans.

Figure 10. Percent of Agencies Offering Benefits to Home Care Aides

*Note: Agencies are required to offer health insurance, so benefits listed are those in addition to health insurance offering.

Home Care Aide Supply and Demand Challenges

A major challenge regularly reported by home care agencies and aides directly relates to the number of hours they work and their hourly pay; this is known as the ‘cliff effect’. This issue emerges from income eligibility requirements of the varying state and federal needs-based programs, such as housing and daycare vouchers. Many home care aides rely on these supports to make ends meet because of the low pay and irregular hours within the home care industry. However, for home care aides to ensure that they remain qualified, they often have to continuously adjust their schedules to not cross over the number of hours worked threshold and become ineligible for the benefits. This is called the ‘cliff effect’ because

15.8% 19.3%

31.6%

63.2%

14.0% 17.5% 21.1%

52.6%

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Disability Insurance Other Retirement Vacation

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19 when individuals hit a particular income point, they ‘fall off the cliff’ and become completely ineligible for these programs and services. When asked how frequently home care aides make schedule changes due to benefit eligibility, over 30% reported that this happened ‘sometimes’, ‘often’, or ‘very often’ (Figure 11).

Figure 11. Frequency of Schedule Changes due to Maintenance of Public Benefit Eligibility

The growth in the demand for home care aides in Massachusetts is well established, with the rapidly expanding aging population who will require the services. This is often considered to be a concern for the future, but home care agencies report difficulty now with finding qualified home care aides to fill the open shifts they have available. In particular, weekend shifts appear to be most challenging, with 12.3% stating that they experience difficulty filling these cases ‘very often’ and 7% reporting it happens ‘often’ (Figure 12). Yet, supply challenges are not just being felt when it comes to off-hour shifts. 7% of the agencies reported that they experienced difficulty filling weekday cases ‘very often’, 10.7% reported it was ‘often’

and 28.6% stated it happened ‘sometimes’. Overall, 46.3% of the home care agencies reported difficulty in filling (either ‘sometimes’, ‘often’, or ‘very often’) weekday cases and 45.6% stated that they had difficulty filling weekend cases. Clearly, this is already a major concern for home care agencies in Massachusetts and it is only anticipated to become much more challenging as demand increases in the near future.

32.7%

36.4%

18.2%

5.50%

7.30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Frequency of Schedule Changes Due to Benefit Eligibility

Percent

Never Rarely Sometimes Often Very Often

(21)

20 Figure 12. Frequency of Difficulty with Staffing Cases

To better understand the current workforce supply challenges of home care agencies, agencies were asked to report their home care aide counts at the beginning and end of a three-month period, as well as document the number of new hires and separations they had over the course of that same time-period.

Separations refer to the number of individuals that left the company, whether voluntarily (quitting) or involuntarily (being terminated). The data presents an illustration of the supply problem home care agencies face in large part due to low recruitment and high turnover (Figure 13). Though the size of the agencies varies considerably (mean= 153 aides), on average, the home care agencies in our sample reported hiring 18 new home care aides over the course of a three-month period (range= 0-81 home care aides). On the other hand, home care agencies lost a large number of home care aides during the same time period, 15 on average per agency, 10 of which left due to termination. This data indicates that, on average, agencies are only adding three additional people to their home care aide workforce once those who leave are taken into account. With the growing demand for home care services, three additional employees a month will not be nearly enough to meet the workforce needs.

28.6% 26.3%

10.7%

7.0%

12.3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Difficulty Filling Week Day Case Difficulty Filling Weekend Case

Percent

Sometimes Often Very Often

(22)

21 Figure 13. Hires and Separations by Agency Over Three Months

Another way to understand the challenges facing the home care agencies related to home care aide supply, is to look at the number of the agency’s home care aide employees that left the agency as a proportion of their total home care aide workforce. This measure is the agency’s turnover rate. For the purposes of calculating the turnover rate, two methods were applied. Agencies were asked to report the number of home care aides that were terminated over a three-month time period. Using this number, divided by the average number of employees the agency employed over the same time period, the average turnover rate across the participating agencies was 7%. However, turnover rates typically include all employees that have left the company, not just those that were terminated. To determine a more global turnover rate, including all employees that separated from the agency during the three-month time period, the reported home care aide count at the start of the time period, the count at the end, and the number of aides hired were used to determine the number of aides that separated, or left the company for any reason during the time period. This new separation number was then divided by the average aides employed over the time period, to produce the turnover rate. The average turnover rate for all separated home care aides across all agencies was 16% for the quarter (January to March 2016) (Figure 14).

Compared to the average turnover rate for all industries nationwide, which is 3.6% annually, this rate is extremely high (BLS, 2017). Even more concerning is the range of rates across the agencies, with the lowest reporting 0% and the highest reporting a 200% turnover rate. Another way to look at the data to understand the current supply challenge for home care agencies related to their home care aide workforce, is to look at the ‘churn’, defined as the amount of change in the workforce that takes place over a specific time period. Using the more global measure for employee separations, the average churn for home care agencies in this sample was 35%, meaning that over a three-month time period, 35% of their home care aide workforce was either newly hired or left the organization. This is an important

0 10 20 30 40 50 60 70 80 90

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

Home Care Aides

Agencies

Aides Hired Aides Separated

Mean Aides Hired:18 Mean Aides Separated:15

(23)

22 measure as it can indicate the level of instability within an organization, as well as provide some insight into the challenges an agency faces in dealing with volatility in their workforce. For instance, with the occurrence of many new hires, terminations and voluntary separations, the human resources staff at the agency may be overwhelmed, not to mention the training staff and nursing supervisors who are required to oversee the onboarding of new aides. This also may impact the home care aides left behind and affect the overall culture of the organizations. High turnover may place an added burden on those ‘stayers’ who must either pick up the slack of those who have left or assist to support those who are new.

Figure 14. Agency Average Quarterly Turnover and Churn Rates

When agencies were asked to identify the top challenges they face related to their home care aide workforce, the 87.7% selected ‘finding qualified home care aides’ as the most pressing issue facing their organization (Table 3). Second to finding qualified aides, 49.1% of the agencies identified ‘home care aide communication/professional skills competence’ as the next most pressing issue, followed closely by home care aide turnover at 45.6%. These challenges echo what is often discussed industry wide as being the primary threats to home care: recruitment, retention and training of the workforce.

Table 3. Top Three Home Care Agency Challenges Related to the Home Care Aide Workforce

Challenge % of Agencies Selected

Finding qualified home care aides 87.7%

Home care aide communication/professional skills competence 49.1%

Home care aide turnover 45.6%

16.2%

35.4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Turnover Rate Churn

Percent

(24)

23 Agencies were asked what the most pressing issues related to the retention of their home care aide workforce. The top reported challenge reported by 59.6% of the agencies was short shifts (Figure 15).

These one to two-hour shifts, often authorized by the Aging Services Access Point (ASAP) overseeing the case, are seen as a threat because they are undesirable shifts. Agencies report that aides much prefer longer shifts, which allows for more time to accomplish the required tasks, as well as time to get to know and build a relationship with the client. Additionally, longer shifts cut down on the amount of travel that aides are required to do throughout the day. With so many of the shifts available being short, agencies are concerned that aides will leave their agency to go to another agency that has longer shifts available or will leave the industry entirely to pursue employment in a field that can guarantee a consistent schedule with longer shift hours. Second to short shifts, 47.4% of agencies felt that the home care aides’ personal stressors were a major challenge to keeping the aides employed. Issues such as lack of child care or other family caregiving responsibilities, inconsistent transportation (which is often required for this job, particularly in rural areas), or other personal life issues like housing or general financial problems all negatively impact a home care aide’s ability or desire to stay in their job. The third most frequently identified issue that agencies felt threatens home care aide’s interest in remaining in their job is the low wages associated with the position. Particularly when the economy is good and unemployment is low, home care aides often have a number of alternative employment options, many that offer higher salaries and more consistent, regular schedules. Home care agencies struggle to compete with these other industries and often lose employees because they are limited in their ability to change scheduling, and have no control of the reimbursement rates set by state and federal programs, such as Medicare and Medicaid.

Figure 15. Challenges to Retention of Home Care Aides

10.5%

12.3%

29.8%

33.3%

37.6%

42.1%

47.4%

59.6%

0% 10% 20% 30% 40% 50% 60% 70%

Inadequate Benefits Conflict with Clients/Family Transportation Issues Sufficient Hours Not Available Works Limit Hours (Cliff Effect) Low Wages Personal Stressors Short Shifts

Percent

Challenges to Retention

(25)

24 Other Home Care Agency Challenges

A

related challenge to the supply and demand issues facing the home care industry is creating a qualified and prepared workforce to meet the needs of an ever-increasingly complex client population. There is no designated funding stream available to home care agencies to provide training to their staff because this cost is considered to be included within the ASAP reimbursement rate to agencies for home care services.

Training requirements are included in the contracts home care agencies sign with the ASAPs, outlined in Table 4. Home care agency responders were asked about the challenges they face related to the training of their home care aide workforce. Nearly 60% of the agencies identified home care aide attendance as their biggest problem (Figure 16). Meeting the required in-service training hours can be difficult to achieve because agencies must arrange for home care aides to come into the office to attend trainings, and many times this forces the aide to give up a shift to attend the training. Second to attendance, agencies identified funding for training as a major challenge. As previously stated, there is no funding available to home care agencies to support the cost of training, which can include paying a trainer, securing space (if not available at their office), supplies for the training, paying the aides to attend, covering the aides shifts (replacement costs) and administrative costs related to scheduling and organizing the training. This is incongruous with other direct care positions and settings, where money is set aside for the purpose of training staff. Personal Care Attendants in the MassHealth Consumer Directed PCA program have free training made available to them through the Homecare Training Benefit, offered by 1199SEIU and the PCA Workforce Council with funding from MassHealth. Skilled nursing facilities have a user fee which provides the industry with available funds to support rate enhancements that go to increase wages and training for the Certified Nurses’ Aides.

Agencies also stated that the availability of training instructors (31.6%) and training materials in languages other than English (22.8%) are both major challenges for them in providing training to their aide workforce. Instructors, often nurses who also have significant clinical responsibilities beyond training, are becoming more difficult to recruit. Those that are employed as trainers must juggle and manage many different responsibilities, and pulling nurses off client cases can be challenging for agencies. Additionally, having access to training material in the native language of the workforce is a crucial need within the industry. Given that 38% of home health aides and 29% of personal care aides were born outside of the United States, it can be implied that many would benefit from having training material available in their primary language. Many of the agencies identified ‘other’ challenges related to training (15.8%), which were categorized and are listed in table 5.

Table 4. Training Requirements for Home Care Aide Positions

Position Initial Training Required Yearly Required In-Services

Homemaker 40 hours 6 hours

Personal Care Homemaker 60 hours 6 hours

Home Health Aide 75 hours 12 hours

Supportive Home Care Aide 87 hours 12 hours

(26)

25 Figure 16. Challenges Related to Training

Table 5. “Other” Challenges Related to Training Other

Scheduling trainings Transportation

Space with needed equipment

Covering shifts of aides while attending training Instructors who can teach in other languages Training that emphasizes home care scenarios Funding to pay for aides for training

Key Findings and Conclusions: Home Care Agency Survey

The data collected from Massachusetts home care agencies that provide services within the State Home Care Program provide important insights into an industry that is often overlooked and under studied. In a time when the older adult population that will rely on long-term services and supports continues to expand rapidly, home care aides and the agencies that employ them provide a critical service that cannot be undervalued. Yet, the industry face significant challenges to ensure ongoing high-quality care to the

10.5%

15.8%

21.1%

22.8%

29.8%

31.6%

52.6%

57.9%

0% 20% 40% 60% 80%

Quality of Training/Materials Other Access to Training/Materials Availability of Training Materials Availability of Training Materials in Languages Other than English

Availability of Instructors Funding for Training Attendance at Trainings

(27)

26 clients they serve. The instability of the home care aide workforce is substantial. Quarterly, agencies lose 16% of their workforce, and though they add new aides at a rapid pace, the replacements barely keep pace with those that are leaving. With an average addition of three new aides per quarter, after accounting for separations, the home care aide supply will not keep up with the impending demand.

Additionally, the variability in turnover at the agency-level is large, with some agencies reporting 200%

turnover in just three-months. Agencies with such a high proportion of their home care aides leaving will struggle to provide services to clients and may experience disruption in care and quality challenges.

Turnover of home care aides must be addressed, as no level of potential recruitment will ever be able to both replace the aides that are leaving while also meeting the growing demand for services anticipated in the coming years. Agencies identified a number of job and personal characteristics that contribute to the high aide turnover. First were the short shifts prevalent in the State Home Care system. Requests for services are often made for one to two hours at a time, and this results in an immense amount of daily travel (moving from one client to the next), and less time with each client to complete their work tasks and build relationships. Agencies report that aides frequently turn these shifts down in hopes of getting longer shifts with one client and often move from agency to agency seeking longer shifts. After short shifts, agencies identified personal stressors in the lives of home care aides as presenting major barriers to their remaining at the job. Given the nature of the workforce, challenges related to finances, housing, child care, health, transportation, and other issues, can all lead to home care aides leaving their jobs entirely, missing work, or being fired due to poor performance or missed shifts. An essential approach to solve these issues is to improve home care aide wages and enhance benefits, as well as connect aides to community resources. Wages was the next most often cited challenge related to home care agency’s ability to retain home care aides in their jobs. The low wages of this workforce greatly threaten agency’s abilities to recruit new workers and to keep those they have. Since the responding agencies all participate in the State Home Care Program, they are reimbursed for their services at predetermined rates set by the ASAP, which include the wages for the home care aides, limiting their ability to increase the pay for these workers.

In addition to confronting the turnover issue, innovative approaches to improving recruitment for the home care industry must be implemented. On average, home care agencies are hiring 18 new home care aides per quarter, barely enough to cover those that have left during that same period. Home care agencies currently report a home health aide vacancy rate of 8.1%, compared to a 4.8% vacancy of all other Massachusetts occupations (Executive Office of Labor and Workforce Development, 2013). Nearly 20% of the agencies reported frequent difficulty with filling weekend cases, with another 26% stating that they often had challenges. These vacancies and resulting challenges in filling needed cases will increase rapidly if new people are not brought into the field to fill open positions. Nearly 90% of the agencies reported that their top workforce challenge was finding qualified home care aides. Encouraging individuals to pursue home care work is challenging, given the difficulty of the work and the low pay.

However, recruitment is especially challenging when the economy is strong, and a number of better paying job options are available. An issue directly related to recruiting new workers into the field and ensuring they are qualified is making trainings available to those who want to pursue a career in home care. Unfortunately, only 50% of home care agencies offer the 40-hour initial homemaker training, only 37% offer the 60-hour personal care homemaker, and only 35% offer the 75-hour home health aide

(28)

27 training. While these trainings, predominately home health aide, are available at community-based training centers or community colleges, they are cost prohibitive to individuals that wish to enroll. Over 50% of agencies identified the lack of funding available for training as a major challenge related to offering and providing training to their staff. In order to bring new people into the industry, as well as retain those who are already employed, offering free initial and on-going training is imperative.

Section 3: Home Care Aide Survey

Survey Development

The purpose of the Home Care Agency Survey was to collect agency-level information about the organization, such as the services they offer, the state or federally funded programs they participate in, and the home care aides they employ (see Addendum C for a full copy of the survey). The goal of the survey data is to help inform the home care network, policymakers and key healthcare leaders about the current status of the home care industry as it relates to the home care workforce.

The second phase of the ‘Data Driven Advocacy’ industry and workforce assessment following the completion of the Home Care Agency survey was a survey designed and disseminated among home care aides employed by agencies that have contracts to work within the State Home Care Program. Over the fall and winter months of 2016, the Foundation developed the initial draft of the survey by drawing upon previous direct care worker surveys conducted nationally or in other states and working with the advisory board to determine the appropriate questions to include. The draft survey was then pilot tested within three home care agencies with a total of 25 home care aides. In addition to the pilot testing, the Foundation worked with a number of consultants who have expertise in survey methodology and/or the direct care workforce. Dr. Christine Bishop from Brandeis, who sits on the project’s advisory committee and is an expert in the direct care workforce, served as one of these consultants. We also sought assistance from the University of Massachusetts Medical School’s Survey Research Center to review the survey and provide guidance on selecting an appropriate sample that would yield the most representative results.

We worked with Abbie Averbach and Robert Gucci, two experienced researchers who provided us with critical guidance on improving the survey as well as suggestions for selecting a sample. During this time, the survey was also reviewed by the Advisory Committee, once again, with direction sought from the home care agency representatives on particular questions that required editing.

The survey included questions related to the home care aides’ demographics (age, race/ethnicity, marital status, primary language, income, education, government benefits), work history (reason for becoming a home care aide, current jobs, length of employment), work characteristics (pay, benefits, hours, training), and work experience (perceptions of the job, satisfaction, support, control, job demands, intent to stay).

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28

Data Collection

The sampling strategy for collection of home care aide surveys was to solicit participation from home care agencies that completed the Agency Survey. A stratified random sample of ten home care agencies that responded to the Home Care Agency Survey (N=58) was used to select agencies for participation in the Home Care Aide Survey. Initially, ten home care agencies were selected from among those agencies that had responded to the Home Care Agency Survey. Agencies were stratified by geography to account for anticipated differences in home care aide experiences depending on their location. Because agency office location does not accurately indicate the geographic coverage of the agency, the agencies were designated by the areas they served, using five geographic regions. Due to this stratification method, agencies could fall into multiple regions, thus as agencies were selected they were subsequently dropped from the list of remaining regions. Initially, two agencies in each geographic region were selected. The geographic distribution of the ten selected agencies were examined and compared to the distribution for all home care agencies that have ASAP contracts. From the initial ten, the western region was underrepresented, so one additional agency was randomly selected for this region. The final geographic coverage of the selected agencies was as follows: 73% cover the Central region (compared to 52% of all agencies), 36% cover the Southern region (compared to 43% of all agencies), 45% cover the Northern region (compared to 41% of all agencies), 64% cover the Greater Boston area (compared to 42% of all agencies), and 36% cover the Western region (compared to 31% of all agencies).

The agencies that were randomly selected for participation (N=11) were contacted via email and through a phone call to invite them to participate. From the initial eleven agencies that were solicited for participation, three refused due to being too busy or lack of interest and two were never reached (after two emails and two phone calls). Replacement agencies were randomly selected from the same region and contacted for participation. Of the originally drawn agencies, 55% agreed to participate, and 100% of the replacement agencies agreed to participate. Any home care aide employed by these agencies, no matter their position or hours, was eligible to take the survey (See Addendum B for a list of home care positions). The home care aide survey was linked to the agency where the aide was employed at the time of the survey. Therefore, it is possible to integrate agency specific data with the home care aide data included in analyses. The name of the agency was clearly stated on the survey and the questions pertaining to their experience on the job, referenced the agency from which the survey was sent.

After agreeing to participate, the agencies were asked to distribute the survey to their home care aides by emailing the survey link, providing paper surveys in their offices, and mailing the survey out to their aides. Two agencies opted not to mail the survey to their aides’ home believing that they could elicit a higher response from email and in-office survey completion. The remaining nine agencies chose to participate in the mailing. All surveys (mailed and in the office) included pre-paid postage to be immediately returned to the study coordinator. The survey was made available in English, Spanish, and Haitian Creole, with one agency translating the survey into Russian for their staff in both paper and online versions. The research staff were made available to assist with completion over the phone if needed by participants. Survey data was collected from the mid-summer through the early fall of 2017. The survey

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29 was open for responses for approximately two months, though the dates varied across agencies depending on when the agency officially opened the survey to their staff.

All outreach and survey material were submitted to the University of Massachusetts Boston Institutional Review Board (IRB) in the Spring of 2017. The project was determined to be exempt from review under the guidelines: 101(B)(2) Educational surveys/anonymous surveys. The survey included clear language indicating that the home care aides’ participation was voluntary, that all information would remain confidential, and that the survey was being collected for research purposes. The survey also described the respondents’ rights as a research participant.

Results

Survey data was collected through online and paper surveys. 3,007 home care aides were eligible to participate in the survey through the eleven home care agencies. 656 total home care aides responded to the survey, resulting in a 21.8% response rate. The majority of the surveys were completed on paper (57.5%), though 45.5% were completed online.

Description of Home Care Aide Respondents: Work Background

The majority of the home care aides that responded to the Home Care Aide Survey identified as receiving training as either a Home Health Aide (HHA) or Certified Nursing Assistant (CNA) (53.5%) or a Supportive Home Care Aide (SHCA) (25.9%) (Figure 17). Given that only 35% of the home care agencies that responded to the Agency Survey reported offering the HHA training to either new or incumbent workers, it appears that many of these aides receive the HHA training from other sources, such as community- based training providers or community colleges. Conversely, the SHCA training is offered more frequently, with nearly 60% of agencies reporting that they offer the Alzheimer’s SHCA class and 39% offering the Mental Health SHCA training program. A much smaller proportion of the responders reported receiving training as a personal care homemaker (PC Homemaker) (7.3%), homemaker (12.1%), or a chore/companion worker (1.3%). For a full description of each of these types of workers, see Addendum B.

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30 Figure 17. Position held by Home Care Aide Respondents (N=645)

*Respondents were instructed to ‘select all that apply’ and their highest position was selected for inclusion in the figure.

Though most home care aides only work for one home care agency (73.8%), 22.5% are employed by two, and the remaining 3.8% employed by three or more (Figure 18). Because of the low wages and inconsistent schedules that are common among this workforce, home care aides often report having to work multiple jobs to meet the needs of their family. Some, as reported here, work for multiple home care agencies to ensure that they receive the hours that they need. Another common approach is to gain employment in other, similar caregiving jobs while also working as a home care aide for an agency. In this sample, 35.3% reported having at least one other caregiving job outside of their position as a home care aide. The most common job was working as a Personal Care Attendant (PCA), with 19.4% of the full sample reporting that they are also currently working as a PCA (Figure 19). Additionally, aides reported being employed as a private caregiver (11.7%), as a CNA (9.5%), in another caregiving position (6.3%), or as a direct care worker in a group home (5%). Finally, 19.2% of home care aides across the total sample work outside of direct care (Figure 20). ‘Other’ industries (9.8%) and food service (5.2%) were the most frequently reported industries that home care aides had jobs, followed by hospitality (3.9%), retail (2.5%), and childcare (2.3%). The top industries responders wrote in under the ‘Other’ category were as follows:

cleaning services, administrative or office staff, security, education, tax preparation or book keeper and real estate. Across all employment options provided in the survey, 47% of the full sample reported having at least one other position, as a home care aide, another caregiving position, or a job in another industry.

1.3% 12.1%

7.3%

53.5%

25.9%

0%

10%

20%

30%

40%

50%

60%

Chore/Companion Homemaker PC Homemaker CNA/HHA Supportive Home Care Aide

(32)

31 Figure 18. Proportion of Respondents Employed by One or More Agencies (N=592)

*Range of employment: Between 1 and 7 agencies.

Figure 19. Proportion of Respondents Employed in Other Caregiving Roles (N=623)

**35% of responders reported having at least one caregiving job beyond their job as a home care aide;

65% of responders reported not having a job outside of their home care aide position(s) 73.8%

22.5%

3.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

One Agency Two Agencies Three or More Agencies

5.0% 6.3%

9.5% 11.7%

19.4%

0%

5%

10%

15%

20%

25%

Employed as a Caregiver in a

Group Home

Other Employed as a Certified Nursing

Assistant (CNA)

Employed as a Private Caregiver

Employed as Personal Care Attendant (PCA)

SETTING THE AGENDA: DATA DRIVEN ADVOCACY TO ADDRESS HOME CARE AIDE POLICY